ANTHRAX

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ANTHRAX

• What we have Seen
• November 14, 2001

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Anthrax Not a New Disease
Not a New Disease Woolsorters Disease
Ragpickers Disease
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Not a New Disease

• Spores of
• Bacillus anthracis
• Clostridium botulinum
• Clostridium tetani

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Anthrax Research In WWI

• Strategy infect livestock and feed of neutral
  trading partners, import into enemy territory
• Germany
• Romanian sheep? Russian troops
• Argentinean livestock ? Allied troops
• U.S.
• Animal feed and horses for export

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The Geneva Protocol (1925)

• Signed but continued to develop weapons
• Canada, France, Belgium, Italy, Netherlands,
  Great Britain
• Russia, Poland
• U.S. signed in 1972

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Anthrax Research in WWII

• Japan
• Bioweapons research in occupied China
• POWs infected with anthrax and others, leading to
  10,000 deaths
• Food, water contaminated
• Pure cultures thrown into homes
• Sprayed from aircraft
• 5000 anthrax-filled bombs produced at Fort
  Detrick
• Allies detonated weaponized anthrax on an island
  near the Scotland coast
• Viable spores persisted until 1986

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Sites of U.S. Bioweapons Effort
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Sites of U.S. Bioweapons Effort
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Sites of U.S. Bioweapons Effort
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BiopreparatRussian Bioweapons Agency

• 6 research laboratories
• 5 production facilities
• Employed 55,000 scientists
• In 1995, estimated 25,000

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Sverdlovsk Anthrax Outbreak, April-May 1979

• 79 anthrax infections (66 deaths) occurred in
  Ukranians living south of Sverdlosk
• Outbreak of GI anthrax attributed to eating
  contaminated meat
• Case-fatality ratio (86) and pathology
  consistent with inhalational, not GI, anthrax
• Boris Yeltsin chief political officer in district

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Epidemic Curve Onset of Anthrax Cases in
Sverdlovsk
Modal time to death 10 days Median time to
death 12 days Case-fatality rate (86)
decreased as outbreak progressed
Last skin disease
Last inhalation case
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Sverdlovsk Aerial View
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Sverdlovsk Region Epi-map
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Sverdlovsk Region Epi-map
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Sverdlovsk Region Epi-map
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Aum Shinrikyo Cult

• Sarin gas in Tokyo Subways
• Drone aircraft equipped with spray tanks
• 3 unsuccessful anthrax attacks in Japan

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Bioweapons Facilities in Iraq
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Fermenters Used to Produce Botulism Toxin
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Al Hakam Single-Cell Protein Production Plant
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9/17/2001
Anthrax 2001 Epidemic Map
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9/22
Anthrax 2001 Epidemic Map
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9/25
Anthrax 2001 Epidemic Map
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9/26
Anthrax 2001 Epidemic Map
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9/28
Anthrax 2001 Epidemic Map
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9/29
Anthrax 2001 Epidemic Map
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9/30
Anthrax 2001 Epidemic Map
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10/1
Anthrax 2001 Epidemic Map
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10/9
Anthrax 2001 Epidemic Map
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10/13
Anthrax 2001 Epidemic Map
Residence of a NJ case
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10/14
Anthrax 2001 Epidemic Map
Residence of a NJ case
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10/16
Anthrax 2001 Epidemic Map
Residence of a NJ case
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10/17
Anthrax 2001 Epidemic Map
Residence of a NJ case
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10/19
Anthrax 2001 Epidemic Map
Residence of a NJ case
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10/22
Anthrax 2001 Epidemic Map
Residence of a NJ case
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10/23
Anthrax 2001 Epidemic Map
Residence of a NJ case
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10/25
Anthrax 2001 Epidemic Map
Residence of a NJ case
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Anthrax Dispersion
Human environmental
Human residence
Environmental only
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Proportion of Anthrax Cases that are
Inhalational, by State
12
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100
100
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Anthrax Clinical Presentation, Treatment, and
Prevention

• Ronald C. Hershow, M.D.
• University of Illinois at Chicago
• School of Public Health

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Features of Case

• Non-specific flu-like prodrome
• Biphasic course
• Mortality (published gt85)
• Need to recognize clusters
• Abnormal chest x-ray

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Chest X-Ray
-Widened mediastinum
-Pleural effusions
-Pulmonary infiltrates
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Early Diagnosis

• Early recognition, rapid antibiotics essential
• 6 of 10 inhalational cases have survived
• Attention to potential environmental exposure
  (Where do you work?, Where have you been?)
• Tachycardia disproportionate to fever, night
  sweats, elevated or normal WBC count with L
  shift, frequent GI symptoms, no rhinorrhea
• Chest radiograph and chest CT if exposure is
  possible

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Treatment

• Adults IV Ciprofloxacin 400 q12h or Doxycyline
  100 q12h 2 additional antimicrobials (?
  Rifampin, Clindamycin)
• 60 days of treatment Switch to PO agents
• Unchanged for pregnant women- maternal
  hepato-toxicity and fetal skeletal/dental side
  effects of doxycycline
• Children-dose adjusted

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Cutaneous Anthrax

• Follows deposition into skin
• Arms, hands, face, neck most common
• Progression from local edema--gt pruritic
  papule--gtvesicle--gtulcer with black eschar
• Can progress to painful lymphadenopathy and
  systemic disease if untreated, mortality 20

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Cutaneous Anthrax
DDX Insect bite Staph (painful) Rare
problems Plague Tularemia
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Cutaneous Anthrax Treatment

• Oral Ciprofloxacin or Doxycycline for 60 days
• If organism susceptible, may switch to PO
  amoxicillin after improvement occurs

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Post-exposure Prophylaxis for Anthrax
Prevention

• PO ciprofloxacin or doxycycline for 60 days, dose
  adjustments for children
• For susceptible strains, PO amoxicillin
  acceptable for children

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Anthrax Vaccine

• All active- and reserve-duty military personnel
• Not available for civilian use
• Dosing - 0, 2, 4 weeks 6, 12, 18 months
  periodic booster
• ? Use in pre-exposure prevention
• Mass vaccination unlikely
• ? Vaccination of essential high-risk personnel

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Anthrax Pathogenesis

• Spores inhaled-(2,500-55,000 spores)
• Spores ingested by macrophages and transported to
  mediastinal lymph nodes
• germination of spores (1-60 days)
• bacteria replicate, anthrax toxins released
  protective antigen, lethal and, edema factor
• hemorrhagic necrosis of lymph nodes, hematogenous
  spread , shock, death
• 50 develop meningitis

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Anthrax Environmental Protection and Detection

• Lorraine M. Conroy, ScD, CIH
• Associate Professor
• University of Illinois at Chicago
• School of Public Health

November 14, 2001
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Prevention

• What are we preventing?

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Prevention

• What are we preventing?
• Injuries and Illnesses
• Exposure

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Prevention

• How are we preventing injuries and Illnesses?
• Exposure Elimination or Reduction (industrial
  hygiene)
• Early Identification and Treatment (medical)

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Industrial Hygiene

• What is Industrial Hygiene?

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Industrial Hygiene

• What is Industrial Hygiene?
• Anticipation
• Recognition
• Evaluation
• Control

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Industrial Hygiene

• Anticipation
• what are potential hazards that may be
  introduced?
• Recognition
• what are potential hazards that have already been
  introduced?
• Evaluation
• how severe are the potential hazards? Are the
  potential hazards truly hazardous?
• Control
• how can potential health hazards be eliminated or
  minimized?

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Hazard Control

• Hierarchy of Controls

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Q A